Waiting Highmark BCBS

[Misha42000 64]

So I have Highmark BCBS and I have completed everything and had my pre-op appt with my surgeon this pat Monday 5/08/17.

She said they would be submitting everything to my insurance for approval.

Today is Friday and I found out surgical coordinator has been out sick all week (God bless her soul) but the wait is killing me.

I'm so anxious and worried I may not get approved.

Patient Selection Criteria for Adults

• The patient is morbidly obese and is at least 18 years of age.
  Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 or a BMI of 35 with ANY ONE or more of the following comorbidities:
  • Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or
  • Cardiovascular heart disease (with objective documentation by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); or
  • Hyperlipidemia; or
  • Diabetes mellitus type II; or
  • Obstructive sleep apnea (OSA); or
  • Obesity-hypoventilation syndrome (OHS); or
  • Pickwickian syndrome ( a combination of OSA and OHS); or
  • Nonalcoholic fatty liver disease (NAFLD); or
  • Nonalcoholic steatohepatitis (NASH)
• Patients should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes.
• The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed; and
• Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member's understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

If the patient does not meet ALL of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Procedure Codes

43644, 43770, 43775, 43843, 43845, 43846

[leelee 0]

I was approved for the sleeve over two weeks ago by Highmark and when I called as per the instructions I was told the procedures (lap band removal with revision to gastric sleeve was 100% covered. Today I got a call from the hospital that they wanted $2000 co pay that must be paid before the surgery would take place. I have been on the liquid diet for the two weeks and don;t want to have to go through it again so I dug into my savings and paid the hospital. Why couldn't they have gotten it right the first time?